In the last 3 months, did your child have any tests, x-rays, bloodwork done? Yes No

Reason and result

Please explain.

Has the child ever had a general anesthetic?YesNo

Reason:

Were there any serious problems associated with the anesthetic(s)?YesNo*Please select

If yes. Explain:*Please explain

Has any family member had any serious problem with anesthesia?YesNo

Explain:*Please explain

Does the child have any medication/food/latex allergies?YesNo

To what

Type of Reaction

Important Information Needed on the Day of Your Child's Surgery:
Please bring a list of the names and exact dosage of all medicine (including vitamins and herbal medicine) your child is
currently taking with you on the day of surgery. This is very important so that we can prescribe the right medicine for your child after surgery.

Does the child currently take any medicine/vitamins/herbs?YesNo

Medication

Why is your child taking it?

How does your child prefer to take medication

Aspirin or ibuprofen in the last 7 days?YesNo

Last date :*Please enter date

What medications does he/she take occasionally?

The child has sickle cell disease?YesNo

The child has sickle cell trait

(A) Heart or blood problemsYesNo

Heart Defect

Bleeding Problems

Heart Murmur

If yes, were you told it is an innocent murmur?YesNo

Any Blood Transfusions

Other

List

Do you see any Specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(B) Lung or breathing problemsYesNo

Asthma/Wheezing.

When?

Croup.

When?

Chronic Bronchitis.

When?

Cystic Fibrosis

Pneumonia.

When?

Other

List Other

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(C) Nervous system problemsYesNo

Autism

Convulsions, Seizures or Fits

Cerebral Palsy

Hydrocephalus

Down's Syndrome

Myelomeningocele

Developmental Delay

Other

List

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(D) Digestive system problemsYesNo

Hepatitis

Intestines or Bowels

Liver

Gastro-Esophageal Reflux

Stomach

Overweight

Other

List

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(E) Glandular problemsYesNo

Diabetes

Thyroid

Other

List

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(F) Birth problems / Premature birthYesNo

Full term

Prematurity

Weeks Early*Please specify how many weeks premature.

Birth Weight*Please specify birth weight.

Artificial Ventilation Needed?

Apnea Monitor

Last used:

Is child twin?

triplet?

Brain Bleed

Other:

Problems after discharge?YesNo

Explain:

Please describe problems.

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(G) Kidney or bladder problemsYesNo

Explain:

Please explain.

Do you see any specialist?YesNo

Name:*Specialist name is required.

Phone:*Specialist phone number is required.

(H) Menstration has startedYesNo

Date of last menstrual period: (mm/dd/yyyy)*Date of last menstral period required (mm/dd/yyyy).

Is there any possibility of pregnancy? YesNo*Please select

If your child is 12 or older, or has started her menstrual cycle, we will need a urine specimen upon arrival to the surgery center.

(R) Has the patient or a close contact of the patient traveled out of the United States in past 21 days?YesNo

Where? *Please select

Other (Comment)*Please describe

Ebola Travel Symptoms (Check all that apply)

None

Fever

Headache

Muscle Pain

Diarrhea

Vomiting

Abdominal Pain

Unexplained Bleeding/Bruising

Your name:

Relationship to child:

Other:*What is your relationship to the child?

DFAC Phone:*DFAC Phone is required.

Primary Phone number:

Secondary Phone number:

Work Phone number:

Preferred time to call: Anytime Daytime Evening

Email Address

Do you give us permission to access medical records from your child's specialist?YesNo

Any comments you have to share with us concerning your child?

Transportation to surgery and home:

Other Transportation*Please specify what kind of transportation will be used.

You need to have arranged for transportation home prior to the day of surgery.

Is your child 18 years of age or older?YesNo

Does your child have an existing Advance Directive?YesNo*Please select

(An Advance Directive is a legal way to make a decision about future medical care. A life threatening illness or injury can happen to anyone at any age.
You can help control your care by recording your choices. The time to do this is before you are sick or injured).
If your child already has an Advance Directive, please bring it with you on day of surgery. If you want more information, visit our Website and click on the link for Advance Directives.
If you would like to speak with someone about Advance Directives, please call our Communication Nurse at 404-785-6712.